Of Inattention and Hyperactivity

Seven years old Ali* was rushing around the school playground pretending to be a rocket. The harassed looking teacher tried to explain to his mother how he never seemed to concentrate in class or sit still, always fidgeting and distracting others. His mother seemed equally helpless and soon after giving Ali a box on the ear, dragged him away, scolding him harshly.

Four years old Shafia* was known to her parents as a stubborn child. They had started despairing of ever getting her into a reputable school. She could not focus on one thing at a time and appeared to get bored of her toys, alphabets, letters and other educational and play material in less than a few seconds. While her mother tried to coach her in remembering colors and letters, she found she could not do so without hitting her daughter after every few minutes. Ultimately she decided to send her to a preparatory centre for getting admission later in the most elite school in Karachi. The headmistress on the first day said that they had special methods for such stubborn kids but they would have to agree for corporal punishment for their child so the centre could ‘mould’ her properly. Soon enough, the centre also gave up as their methods had only succeeded in developing a fear of studies in the little girl who now quaked at the sight of a pencil and a copy, refusing to touch it at all.

IPP. PN Shifa

Quite often many such cases pass by undiagnosed, where inattention or hyperactivity and impulsivity are the main symptoms. More often than not, they are dismissed as being just kids, or labeled as naughty and punished accordingly. Parents blame teachers for not making the subjects interesting and teachers blame parents for not handling their offspring in a better manner. At the end of it all, it is the child who suffers.

ADHD or attention deficit hyperactivity disorder is a disorder characterized by a combination of lack of attention with features of hyperactivity and impulsivity. Psychologists use criteria provided in the Diagnostic and Statistical Manual for Mental Disorders (DSM IV TR) to see if a patient fulfils the minimum six symptoms requirement of either inattention or hyperactivity and impulsivity or both. In case the latter is missing, the diagnosis may be of ADD or attention deficit disorder only where a child is able to sit in one place for more than a few minutes but is not able to focus on his work continuously, loses necessary work items frequently, fails to carry out instructions and even fails to listen when spoken to directly. The diagnosis of hyperactivity/impulsivity disorder seems imminent when a child is always on the go, fidgets a lot, is unable to sit when situations demand it and interrupts or intrudes or has difficulty awaiting his turn.

The ‘cure’ for a child with ADHD does not lie in harsh parenting. Correct diagnosis is the key to more than half the problem. Detailed clinical interviews along with certain pen and paper tests taken from the child and the parents help in diagnosis. Psychologists and remedial teachers alike can provide help through structured programs for parents and children. Exercises and games are conducted with children in individual settings that help them in focusing, reducing impulsivity and gaining a greater degree of control on their actions. Psychiatric help is necessary in establishing a correct dosage of methylphenidate (Ritalin) as the growing child requires medical support to help him focus. Controversy surrounds the idea of drug administration to children yet researches suggest that the benefits far outweigh parental concerns of dependency.

Psychological help can also be provided in cases of ADHD. In fact many psychologists stress on reducing dependency on drugs and on utilizing a behavior based approach to reduce problem behaviors. In Pakistan, Applied Behavior Analysis or ABA is a relatively new phenomenon. This approach involves utilization of behavior principles such as rewards and different types of plans for focusing on different problems. For e.g. with a child who has a mild level of inattention during class, one of the ABA approaches may be to establish a baseline for the number of times he looks up during his work and then applying a reward system for the swiftness with which he manages to complete his work and then allowing him an early break. Eventually, the premise is that he will be able to develop inner controls and a post intervention analysis will reveal a change in behavior when compared to the baseline.

Institutes such as the Institute of Professional Psychology at Bahria University, Karachi, have initiated the teaching of ABA as a subject in Pakistan. The theses and projects produced by the students here show a strong link between the control of symptoms of ADHD and the application of ABA principles. Young patients are treated at the Institute’s PN Shifa outpatient department using behavior principles and parental guidance sessions are carried alongside to ensure the usage of these at home.

Child's play haven at IPP, PN Shifa, Karachi.

*Names and symptoms have been completely changed and adapted to suit the article. Yet, they are based on true accounts and observations of patients at my workplace.